colostomy care lecture
TRANSCRIPT
ENTEROSTOMAL THERAPY
“entero”- intestine“stoma” – opening, mouth
SCOPE >provision of acute and rehabilitative
care for people with select disorder of GI, GU and Integument.
ET nurse- plays a pivotal role in the guidance of optimum care for ostomates.
ROLES OF ET NURSE1. Clinician2. Educator 3. Consultant4. Researcher 5. Administrator6. Coordinator7. Change Agent8. Counselor
ET Nurses Activities for Stoma Patients
I. Pre-Op PhaseCounseling
>Emotional Support >ensures accurate knowledge >treatment and discharge planning
Site Selection > Marking / Stoma Siting a. evaluate body positions
II. Pre-Op Phase 1. Selection and Fitting of appliance 2. Counseling III. Post-Discharge Phase 1. encourage for regular follow-up 2. Joining them to Ostomy Association
of the Philippines or any local Ostomy Groups
3. Informing other support services (Stoma Care Clinic) 4. Acts as liaison
Gastrointestinal System
Food enters through the mouth and is broken down by saliva and the act of chewing. It passes through the esophagus until it reaches the stomach. The stomach uses acids and enzymes to convert food into a semi-liquid state called chyme. The stomach then expels the chyme into the small intestine. The small intestine is the portal for all nutrients to enter into the bloodstream. Crucial digestive enzymes and hormones secreted from the pancreas, liver, and gallbladder break down the semi-liquid chyme into molecules small enough to be absorbed into the bloodstream. Any leftover food goes into the large intestine, where it is converted into solid waste with the help of bacteria. Water and salts are extracted from any undigested food. The end-product is expelled through the rectum and anus.
Colon>Greek word “kolon”>runs from the cecum to the rectum.>measures about 5 ft (1.5 m) in
length>Functions: 1. absorbs water from digested food 2. moves the stool through the
rectum
Rectum an eight-inch chamber that connects
the colon to the anus. The rectum:Receives stool from the colon Lets the person know there is stool to be evacuated Holds the stool until evacuation happens
*When anything (gas or stool) comes into the rectum, sensors send a message to the brain. The brain then decides if the rectal contents can be released or not. If
they can, the sphincters relax and the rectum contracts, expelling its contents. If the contents cannot be expelled, the sphincters contract and the rectum accommodates so that the sensation temporarily goes away.
The anus is the last part of the digestive tract. It consists of the muscles that line the pelvis (pelvic floor muscles) and two other muscles called anal sphincters (internal and external). The lining of the upper anus is specialized to detect whether the rectal contents are liquid, gas or solid.
Major Blood Supply
1. Celiac Artery-stomach and 1st portion of small intestine (duodenum)
2. Small Mesenteric Artery (SMA)- small bowel from the ligament of
Treitz up to the transverse colon3. Inferior Mesenteric Artery
(IMA)- from mid-transverse colon up to the
rectum
Specific Functions:
1.) Ascending Colon
Absorbs water
Vitamin K production
Storage of bacteria
2.) Transverse Colon
“the only mobile portion of the colon”
3.) Descending Colon
Solidification of foods, convert to stool
4.) Rectum
Reservoir for stool
Distal portion merges with anus
TUMORS OF THE GIT1. Benign
Adenoma >pre-malignant >most common-colon >Hamartomas >Lipomas2. Malignant
Adenocarcinoma >arising from adenomas >common-colon
RISK FACTORS
Age 60 years old
Polyps
Familial Tendency
Diet
>red meats
>foods high in fat
Irritable Bowel Disease
PROTECTIVE AGENTS
High Fiber NSAIDs and COX2 inhibitor
WARNING SIGNALSChange in bowel habitsBlood in the stool
TUMOR STAGING
STAGE EXTENT OF DISEASE
SURVIVAL AFTER 5 YEARS
I Only portion of bowel wall
75%
II Beyond whole bowel wall
60%
III Lymph nodes 30%
IV Distant organs (liver, organs)
metastasis
5%
Types of Abdominal Stoma
1.) Ileostomy2.) Urostomy
3.) Colostomy*nomenclature depends on locationEx. Cecum-cecostomy Sigmoid-sigmoid colostomy
INDICATIONS
Disease : Cancer Diverticulitis Mega Colon
Congenital: Hirschprung’s Disease Rectal Atresia
Mega ColonTrauma : Stab wounds – “life saving”
Gunshot Impaled Injury
Special Considerations
Use of skin barriers---active enzyme
Increase fluid intake
Chew foods well
Avoid highly fibrous, oily and fatty foods
Medications (depending on physician’s prescription)
TYPES OF COLOSTOMY APPLIANCES
1.) One-Piece SetSingle use / disposableEasy to applyFlexible Conforms well to body contours Available in pre-cut / cut to fit style Wafer and pouch included in one single piece Disadvantage: can cause skin irritation due to frequent changing / removal of wafer
1.) Remove pouch from top to bottom while maintaining gentle pressure on the skin around the stoma with the other hand.
Application of One-Piece System
2.) Clean the peristomal skin with mild soapy water or cleanser. Rinse skin and pat try.
3. Put a finger through the hole in the skin protector to separate the inner surfaces of the pouch. Ensure that the pouch does not adhere together before applying it.
* If you use a drainable pouch, make sure you put the clamp on before applying it.
4. Peel off the paper / plastic backing from the skin protector.
5. Fold the skin protector in half and position the bottom of the skin protector opening around the base of the stoma.
6.) Lightly massage the bottom part of the skin protector and work upwards
7.) Smooth the entire surface of the skin protector, working from the bottom to top, to ensure good adhesion.
2.) Two-Piece Set
Security
Easy access to stoma
Minimized skin stripping
Economical-wafer can remain on body for 3-4 days
Application of Two-Piece System
1.) Remove used pouch. Grasp the pouch tab (depending on product manufacturing) gently and pull from top to bottom.
2.) Gently peel off the flange / wafer. Press down gently on the adjacent skin with one hand while you peel off the flange / wafer.
3.) Clean the peristomal area with mild soapy water or cleanser. Rinse and pat dry.
4.) Trace your stoma size using the transparent cover from the package.
* Use the traced plastic cover.
5.) Use the cut out plastic cover to trace the stoma size onto the white paper backing on the flange / wafer.
* Cut the skin protector using a pair of curved scissor.
6.) Peel the paper / plastic backing from the center of the flange and place it over the stoma.
7.) Lightly massage the skin protector with your finger to ensure good adhesion around the stoma. In most cases there should only be a little or no exposed skin between your stoma and the skin protector.
8.) If present, remove the outer paper / plastic backing from the flange. Adhere it onto the skin ensuring that there are no creases.
9.) Open the flange lock by moving the lever upward without forcing. This is only a small movement.
10.) To fit the plastic ring, press pouch and flange together starting at the bottom. Run fingers around the bottom. Run fingers around the coupling system / ring from bottom to top: when a slight click is heard the pouch is securely positioned.
11.) Push the lever down to lock the system.
12.) A gentle tug downward on the pouch will confirm that the pouch is safely locked in place.
ComplicationsFolliculitis
Redness at the base of the hair follicle around peristomal skin.Causes:
Hair follicle is removed aggressively by adhesive, causing irritation and infection.Treatment:
> Regularly shave the peristomal area.
Product Skin Allergy
Obvious outline of skin barrier around stoma with signs of redness, soreness, itching, etc.
Causes: Allergic reaction Treatment: Change of appliance/
product
.
Redness, soreness, rash, weeping area,
blister, bleeding, ulceration….etc
Causes: Poorly sighted Leakage, allergies,
infection radiation, skin stripping
Treatment: Identify cause
ProlapseIntestine is pushed outwards through the stoma. The exposed mucous membrane is more inclined to bleeding.
Causes: Weight gain Overstraining of peritonuem Insufficient fixation of stomaTreatment: Use a larger appliance to
contain to contain the stoma. For severe cases, consult your
surgeon for further treatment.
HerniaAbdominal wall protudes in the area of a stoma- “weak point” of the abdominal walls.
Causes: Overstraining of peritoneumTreatment: Strenous physical
exercise/work should be avoided.
For severe cases, consult your surgeon for further treatment.
Retraction
The stoma retracts below the skin level
Causes: Weight gain Insufficient fixation of
stoma TraumaTreatment: Use appliance with
convexity For severe cases, consult
your surgeon for further tratment.
Guide to Documenting
Stoma Shape: Round, Oblong Color: Red, pinkish, bluish, black Surface: Moist, Bloody, dull, dry, cracked
Peristomal Area Smooth, intact, blistered, ulcerated, excoriated
Drainage / Stool Consistency: Formed, watery, semi-formed, mucoid Odor: Non-odorous, malodorous, pungent Color: Brownish, greenish, yellow, black
A stoma is not a hindrance. > Most people can enjoy a healthy sex life and
have babies. > Regular Exercise to maintain body fitness and
health. * Avoid sports that might injure the stoma and
sports that put too much stress on the abdominal muscles.
-what to avoid: weight lifting, rowing -what is encouraged: swimming, cycling, hiking,
skiing. > When health is restored, think of returning back
to work. > You can wear anything you like.
Benefits of active lifestyle
1. Helps body recover faster
2. Helps reduce excessive weight and maintain healthy body weight.
3. Helps to gain confidence and maintain a positive attitude.
4. Helps to keep you healthy and feeling good.
Usually, a specific diet is not required. General rules of a well-
balanced diet will apply.Check first with your surgeon when can normal diet be resumed. Try different foods in small portions if you suspect they have caused problems.Avoid foods that may cause diarrhe, constipation, gas and odor.Check with surgeon / stomal therapy regarding medications.
*Take regular meals *Eat dietary fibers (colostomates)*Drink plenty of water*Eat a balanced diet*Restric alcohol beveragesAvoid fatty foods.
Dietary Guide for Ostomates
Foods that increase odor
asparagus, broccoli, cabbage, cauliflower, beans, eggs, fish, onions, spices
Foods that increase gas
beans, beer / carbonated soda, broccoli, cabbage, cauliflower, corn, cucumbers, mushrooms, peas, radish
Dietary Guide for Ostomates
Foods that thicken stool applesauce, bananas, cheese, boiled milk,
marshmallows, pasta, peanut butter, pretzels, rice, bread, toast, yogurtFoods that may loosen stool
green beans, beer, broccoli, fresh fruits, grape juice raw vegetables, prunes / prune juice, spicy foods, fried foods, chocolate, spinach, leafy green vegetables
Dietary Guide for Ostomates
High fiber foods that may cause blockages
dried nuts, grape fruit, nuts, corn, raisins, celery, popcorn, coconut, seeds, coleslaw, Chinese vegetables, oranges
Where to get help?
Stoma Care Team
Adrianne Gonzaga, RN- Head / Trainor
Rhyan Hitalla, RN- In patient Coordinator
John Frondoso, RN- Home Care Coordinator
*Call the Supervisor-on-duty for referrals and problems that may arise in stoma patients